COMMON NECK

SWELLINGS
• PRESENTED BY :
• Ali Abdirahman 221-083011-22882
• Abdullahi Abdikarim 221-083011-22890
 Outline

• Anatomy
• Classification
• Etiology
• Patient approach
• Investigations
• References
 Anatomy of the neck

• The neck is divided into anterior and posterior triangles by

the sternocleidomastoid muscle.
• The anterior triangle extends from the inferior border of the
mandible to the sternum below, and is bounded by the
midline and the sternocleidomastoid muscle.
• The posterior triangle extends backwards to the anterior
border of the trapezius muscle and inferiorly to the clavicle.
The upper part of the anterior triangle is commonly
subdivided into the submandibular triangle above the
digastric muscle and the submental triangle below.
 Continuation

• BOUNDARIES OF THE Anterior triangle

• Medially; anterior median line of the neck.
• Anteriorly; inferior border of the mandible.
• Laterally; anterior border of SCM
• This triangular region is used for approaching
important structures in the neck e.g. larynx, trachea
and thyroid gland
Anatomy
 Cont

• Using the digastric and omohyoid muscle. Anterior

triangle can be divided into;smaller
submandibular,submental,carotid and muscular
triangles
Contents;
• supra and infrahyoid muscle
• vessels including; (common carotid and its branches,
external and internal carotid artery, internal jugular
vein and its tributaries).
 BOUNDARIES OF Posterior
triangle
• Anteriorly; posterior border of Sternocleidomastoid
• Posteriorly; anterior border of the trapezius mm
• Inferiorly; middle 1/3 of the clavicle
• Apex; superior nuchal line of occipital bone
Its divided into 2 triangles by the inferior belly of the omohyoid muscle.
• An upper or occipital triangle
• A lower or suA)Nerves and plexus
• bclavian/supraclavicular triangle.
• Contents: nerves and plexus, muscles, lympth nodes,
• DEVELOPMENT: anterior: 1st pharyngeal arch
• Post: 2nd pharyngeal arch
 NECK LUMPS
• Majority are lymphadenopathy following infection especially
in children.
• Diagnosis of a lump in the neck is partially based on age of
patient.
• In children they are common though rarely malignant but an
adult with a lateral neck swelling has cancer until proven
otherwise.
• Features that suggest malignancy are progressive enlargement,
hardness, lack of tenderness, fixation to deep structures and
size. (node >1cm diameter is likely to be malignant)
 Diagnosis of the neck lump

• History
• Physical signs
• Size
• Site
• Shape
• Surface
• Consistency
• Fixation: deep/superficial
• Pulsatility
• Compressibility
• Transillumination
• Bruit
 Classifications:

Location (Midline or Lateral).

Etiology (Congenital or Acquired).
Consistency (Solid or Cystic).
 Midline neck Swellings :

I. SOLID SWELLINGS:
GLANDS:
Lymph nodes ( submental, prelaryngeal or pretracheal).
Thyroid gland isthmus nodule.
Median ectopic thyroid tissue.
SUBCUTANEOUS:
 Lipoma of Burn’s space (Suprasternal notch).
 Midline neck Swellings
• II. CYSTIC SWELLINGS:
FLUID:
Thyroid gland cyst in isthmus.
• Thyroglossal cyst.
• Dermoid cyst (Sublingual or Suprasternal).
• Subhyoid bursa.
• Sebaceous cyst.
ABSCESS:
• Cold abscess.
• - Pyogenic abscess.
BLOOD :
• Hemangioma.
• Aneurysm (Innominate artery).
 ETIOLOGY:
ACQUIRED:

INFLAMMATORY:
• Acute inflammation. E,g lymphadenitis
• Chronic inflammation.
• Non-specific.
• Specific e.g. T.B lymphadenitis.
NEOPLASTIC
• Primary e.g. lymphoma.
• Secondary metastasis.
• TRAUMATIC
• Hematoma
• pseudoaneurysm
CAUSES OF CERVICAL LYMPH
NODE ENLARGEMENT
• BACTERIAL-Strep, TB, Cat scratch fever
• PARASITES-Toxoplasmosis
• VIRAL-Infectious mononucleosis, herpes simplex,
rubella, pharyngitis, HIV
• MALIGNANCIES-Lymphomas, oral metastases,
thyroid
Cervical lymphadenopathy is either inflammatory
or neoplastic
 CLINICALLY
INFLAMATORY MALIGNANT

Usually painful Painless

Firm Hard

Mobile Maybe fixed

Signs of inflammation Signs of primary head and neck cancer

 LYMPH NODE LEVELS IN
THE NECK
• LEVEL I: submental and submandibular
• LEVEL II: upper jugular
• LEVEL III: middle jugular
• LEVEL IV: lower jugular
• LEVEL V: posterior triangle
• LEVEL VI: anterior compartment(visceral)
• LEVEL VII: upper anterior mediastinal
 TNM CLASSIFICATION OF
REGIONAL LYMPH NODES
• No- No regional metastases
• N1-single ipsilateral LN 3cm or less
• N2a-single ipsilateral LN 3cm -6cm
• N2b-multiple ipsilateral LNs not more than 6cm.
• N2c-Bilateral or contralateral LNs no more than
6cm.
• N3-metastasis in a LN more than 6cm.
 GOITRE

• Examine when the neck is slightly extended.

• If thyroid is diffusely enlarged: TSH mediated or
autoimmune enlargement.
• If its soft- dyshormonogenesis,, diffuse goitre of
puberty.
• If firm/hard-autoimmune thyroiditis
NOTE the firmer the texture of the enlarged thyroid
the more likely is the pathology to be autoimmune,
 INVESTIGATIONS:

• TSH
• Serum T3, T4 & TSH.
• Thyroid scan
• Ultrasonography (differentiates ‘solid’ from
‘cystic’ nodules’).
• Fine needle aspiration biopsy (FNAb).
 TB LYMPHADENITIS

• Chronic painless mass in the neck,

persistent ,usually grows with time.
• Referred 2 as cold abscess coz there is no warmth
and overlying skin is bluish purple color.
Accompanied symptoms;
• fever, chills, malaise and wgt loss.
• Skin may becomes adhered to the mass and may
rupture forming a sinus and an open wound.
Stages of Tuberculous lymphadenitis

1. Stage of infection, and lymphadenitis

2. Stage of periadenitis with matting
3. Stage of caseating necrosis and cold abscess formation
4. Stage of formation of collar stud abscess
5. Stage of formation of sinus which discharges yellowish caseating
material
• DX: FNAB
• Excisional biopsy
• RX-surgical excision may spread the to other organs.
• If surgically removed has a high rate of recurrence and forming a fistula
 CONGENITAL/
DEVELOPMENT
• Epidermal/dermoid cyst
• Brachial cyst
• Thyroglossal duct cyst
• Vascular tumors
• laryngocele
DERMAL/EPIDERMAL CYST
• A developmental abnormality inclusion of ectoderm along the lines of
infusion thus in the neck they are always midline & usually above the
hyoid bone.
PATHOLOGY; the cyst wall is usually thick and lined by stratified
squamous epithelium containing skin appendages-hair follicles,
sebaceous and sweat glands.it contains hairs and cheesy epithelial debris.
• CLINICALLY:Cystic painless mass in the midline of neck btn submental
region and suprasternal notch.
• Not translucent & not attached to underlying skin.
• In submental dermoids, sometimes there is a swelling pushing the tongue
upwards.
 BRACHIAL CYST

• Smooth fluctuant mass level 2.

• Arises 4rm the embryonic remnants of the 2nd brachial cleft.
PATHOLOGY
Its lined by sq stratified epithelium and most have lymphoid
tissue in the wall.
Contains straw colored fluid rich in cholesterol.
INCIDENCE
Mostly in young adults.(3rd decade)
Brachial cyst
 CLINICALLY

• Slowly growing painless soft cystic swelling

x.tically under the anterior border of the upper and
middle 1/3 of the SCM muscle.
• Not translucent and doesn’t move on swallowing.
INVESTIGATIONS: FNAB yields a cellular fluid
rich in cholesterol
RX-Surgical excision via a transverse neck incision.
DDX-cold abscess, lymph cyst
 THYROGLOSSAL DUCT
CYST
• Abnormal development due to persistence of a part of thyroglossal tract
(extends from the foramen cecum 2 the isthmus of the thyroid gland.)
• Most common congenital neck mass.
• Mean age is 5yrs.
• It lies at any point along the migratory pathway of the thyroid gland
but its always near or in the midline of the neck.
• 50% are close to or just inferior to the body of the hyoid bone, they may
also be found at the base of the tongue or close to the thyroid cartilage.
• Sometimes a thyroglossal cyst is connected to the outside by a fistulous
canal a thyroglossal fistula which arises secondarily after rupture of a
cyst.
 CLINICALLY

• Midline painless neck cyst that moves up and down

with swallowing and on tongue protrusion.
• Sometimes may present as an infected cyst.
RX
surgical excision of the cyst and tract including the
body of the hyoid bone.
 CYSTIC
HYGROMA(LYMHANGIOMA)
• Rare malformation of the lymphatic system that
usually presents as a posterior neck swelling.
• Its due to sequestration of a portion of jugular
lymph sac 4rm the lymphatic system.
ETIOLOGY-sequestration of a portion of the lymph
ducts 4rm the lymphatic system
The swelling consists of an aggregation of cysts like a
mass of soap bubbles each filled with lymph.
 INCIDENCE
60% at birth, 75% by 1yr, 90% by 2nd year
CLINICALLY
• Soft easily compressible translucent, fluctuant, ill defined posterior neck
swelling.
• May spread into cheek, floor of mouth, tongue, parotid and ear canal
• Stridor d/t tracheal displacement with mediastinal involvement.
• DX: CT with contrast
RX
• Surgical via a neck incision
• Total excision may be difficult and may not occur.
C.H in new born
 LARYNGOCELE

• Its an air filled dilatation of laryngeal ventricle and

saccule due to herniation of laryngeal mucosa.
TYPES
Internal(20%)-confined to the interior of the
larynx.
External (30%) expands into neck through
thyrohyoid membrane.
Combine (50%)
Cont
 ETIOLOGY

• Thought to prevail in blowing jobs e.g. in trumpet players .

• Coexistence of laryngeal cancer (acts as a valve allowing air
under pressure into the ventricle.
INCIDENCE:
Male; female (5:1) 20% bilateral
CLINICALLY;
• Hoarseness of voice and stridor, lateral neck swelling that
increases by Valsalva’s maneuver.
• 10% infected sacs( laryngopyocele)
 INVESTIGATIONS

• X ray and CT scan shows air within the sac.

• TREATMENT
• Endoscopic excision for the internal type.
• Lateral external approach excision for the external
and combined type.
 PAROTID GLAND
SWELLINGS
ETIOLOGY
• Acute viral parotitis (mumps)
• Acute suppurative parotitis (parotid abscess)
• Autoimmune parotitis e.g sjogren’s syndrome
parotid tumours e.g benign (pleomorphic adenoma-
adenolymphoma ( Warthin’s tumour).
• Malignant e.g adenocarcinoma (mucoepidermal
carcinoma).
 CLINICALLY

• Diffuse or localized swelling.

• Diffuse swelling leads to elevation of the ear lobule
and obliteration of normal furrow btn mandibular
rami & mastoid process.
• Facial nerve function should always be verified.
• Can present as neck masses.
 CAROTID BODY TUMOUR

• The carotid body: discrete paraganglion located in

the adventitia of the postero-medial aspect of the
carotid bifurcation.
• Functions as a chemoreceptor responding to changes
in oxygen, CO2 and Ph by regulating ventilation.
• A carotid body tumour is a slowly growing
paraganglioma arising from the carotid body with
very rare proven metastases.
 INCIDENCE
• Age-50yrs.
• Higher in oxygen deprived individuals mainly those who live at high
altitudes.
CLINICALLY
• Painless, slowly growing neck swelling in the carotid triangle.
• On palpation: firm rubbery potato tumor and pulsatile.
• It may decrease in size with carotid compression. Mobile from side to side
but not up and down.
• INVESTIGATIONS: Carotid angiography (typical widening of carotid
bifurcation).
• CT & MRI (determine its extent).
 CAT SCRATCH FEVER

• Benign subacute illness caused by Bartonella henselae x-

terized by regional lymphadenitis following scratch of a cat
• Incidence 7/100000
• Flu like symptoms < 50%
• Pre-auricular/level1 nodes
• Resolution in 90% without Rx.
Rx.
azithromycin
 NEOPLASTIC

• BENIGN
• Pleomorphic adenoma, Warthin’s, Schawannoma,
thyroid adenoma, carotid body tumour
• MALIGNANT
• Primary (lymphoma, carcinoma, sarcoma)
• Secondary(breast, lung, GI)
 PRIMARY TUMOURS

• Lymphoma
• Thyroid
• Salivary gland
• Neurogenic
• Paraganglioma
• NEUROGENIC:Schwannoma, Neurofibroma.
Malignant neural tumours
 SCHWANNOMA

• Solitary encapsulated
• 50% H&N
• 4th/5th decades
• Female predominant
• FNA difficult
• CT/MRI
• NB.5% MALIGNANT
 NEUROFIBROMA

• Firm benign encapsulated tumour resulting frm

proliferation of schwann cells in a disorderly
pattern involving nerve fibres
• Usually multiple
 Approach to a patient with a
neck swelling
• History
• Exam
• investigations
 Approach to patient

• Rule of 7 in the neck

• 7 days—inflammation
• 7 months—neoplasm
• 7 years—congenital defect
• Note: The Rule of 7 provides a probable diagnosis
of the neck mass based on the average duration of
the patient’s symptoms
 Rule of 80 in the neck

• 80% of non-thyroid neck masses are Neoplastic

• 80% of Neoplastic neck masses are seen in males
• 80% of Neoplastic neck masses are malignant
• 80% of malignant neck masses are metastatic
• 80% of metastatic neck masses are from primary
sites above the clavicle
 History
• A careful history can provide important clues to the diagnosis of a neck
mass.
• Duration of symptoms is one of the most important points in the history.
• Inflammatory neck masses are usually acute in onset and resolve within
several weeks.
• Cervical lymphadenitis, the most common cause of neck masses, is often
associated with upper respiratory tract infections
• A history of coughs, fever, sore throat, recent travel, dental problems, and
insect bites should be sought.
• Congenital neck masses are often present for an extended duration —
sometimes, but not always, since birth. For example branchial cysts
usually present in young adults in their twenties
 History

• Malignant neck masses, as in metastatic carcinoma

to cervical lymph nodes, tend to have a history of
progressive enlargement. The most common origin
of these metastases is squamous cell carcinoma of
the upper aero digestive tract.
• More than 80% of these tumours are associated
with tobacco and alcohol use in persons over 40
years of age. These features should be identified in
the history
 Cont

• Further features of malignancy include voice

change, odynophagia, dysphagia, haemoptysis and
previous radiation, especially with thyroid
tumours.2
• EXAMINATION: Examination should include the
mass itself, the rest of the neck, the skin of the head
and neck and the ENT system (ears, oral cavity,
nasal cavity, nasopharynx, oropharynx,
hypopharynx and the larynx)
 cont

• The size, consistency, tenderness and mobility of the mass

provide diagnostic clues. Acute inflammatory masses tend
to be soft, tender and mobile.
• Chronic inflammatory masses are often non-tender and
rubbery and either mobile or matted.
• Congenital masses are usually soft, mobile and non-tender
unless infected.
• Vascular masses may be pulsatile or have a bruit.
• Malignant masses may be hard, nontender and fixed.
 Cont

• The scalp and skin of the head and neck should be

examined for primary cutaneous tumours.
• Recent bite marks/scratches may indicate cat
scratch disease
• Cranial nerve examination is also necessary.
• INVESTIGATIONS: CBC, serology, tuberculin
test, chest xray, ct scan, MRI,FNAC, laryngoscopy,
endoscopy,open biopsy
• THANKS FOR LISTENING
 References

• SRB's Manual of Surgery

• Bailey and loves short practice of surgery